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THERAPY DIRECTION

Discourse – on co
In late 2004 the Stirling Discourse Colloquium considered current and future approaches to the analysis and treatment of disordered communicative interaction. While some of its individual papers are to feature in a special issue of Aphasiology, we have the opportunity to eavesdrop on a discussion among the main participants: Linda Armstrong, Suzanne Beeke, Steven Bloch, Richard Body, Marian Brady, Chris Code, Caroline Davidson, Ruth Herbert, Simon Horton, Catherine Mackenzie, Catherine Niven and Mick Perkins...

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READ THIS IF YOU ARE LOOKING AT DISCOURSE AND WANT TO • FEEL MORE CONFIDENT IN WHAT YOU ARE DOING • CHOOSE THE RIGHT ANALYSIS TOOL AT THE RIGHT TIME • GET THE MOST OUT OF CLINICAL CONVERSATIONS

Picture of Stirling Castle from VisitScotland / Scottish Viewpoint. See www.visitscotland.com.

uantitative and qualitative approaches to analysis of a communicative interaction are seen as opposite ends of a continuum. This continuum stretches from • highly structured sampling to unstructured naturalistic ‘real-life’ interactions • measurable and quantifiable approaches to the narrative description of discourse features • group to individual level data • broad brush to very fine-grained analysis. While some entrenched radicals probably remain uninterested in alternative approaches, most individuals are more flexible, as both analysis tools do a particular job. The analysis approach should be dictated by the information you seek to collect and the function the results will have. If you want to compare an individual’s performance to that of a wider population of people you need to analyse the data in a quantitative manner. If you want to explore an individual’s performance within a peer conversation then you will use a qualitative method. It is possible that different clinicians naturally ask different questions. Having a predisposition may lead us to think that one of these approaches would be more or less informative than the other, which in turn would have a greater or lesser influence on the clinical intervention. Unless a clinician is comfortable with a given approach, the results and the utilisation of the analysis may be limited. Normal conversations are complex so analysis will be based on ‘messy’ data. Some researchers have begun to look at ‘co-construction’ but we have yet to develop an understanding of how normal conversations really work. There is a myriad of subtle and hidden activity that conversational partners do or achieve through their talk of which we have only just begun to become aware, for example in turn-taking negotiation or making a complaint. We should also consider the possibility that a disordered pattern of discourse features is only a symptom caused by an underlying impairment. Perkins (2005) has highlighted the possibility that pragmatic impairment may be a compensatory adaptation. In the past, we have focused on treating symptoms but consideration should also be given to the impairment(s) within a broader context. In addition, it is important to consider the limiting constraints of existing cognitive resources, ageing and any brain damage that may moderate our expectations of change in the client’s communicative behaviour.

Joint responsibility
A key benefit of a qualitative approach is that it forces us to consider the joint responsibility of both the communicatively impaired individual and their conversational partner. Communication impairment affects both individuals’ talk and has an impact on the nature of the communicative interaction. In some cases communicative partners collaborate to achieve a successful interaction. The communicatively-able

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

THERAPY DIRECTION

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participant may use positively adaptive supportive techniques, for example collaborative repair, which enable a communicatively impaired individual to make a greater contribution. In Perkins et al. (1999), one researcher’s contribution to an interaction altered between a group of people with non-fluent aphasia and a group with fluent aphasia. A computer program automatically identified and quantified a set of linguistic and discourse features in a transcribed corpus of conversational data. The researcher was consistent on some measures of conversational interaction, but not on others. It is likely that they adjusted their contribution, when required, to compensate within the interaction for communicating with individuals with different communicative abilities. Alternatively, the compensatory behaviour employed by a communicatively competent speaker may be maladaptive, for example the use of ‘testing’ within the conversation. This type of behaviour is not conversational, introduces an institutional flavour to the interaction and may reflect the conversational partner’s subtext in entering into the conversation. Similarly, the experience or familiarity of the non-communicatively impaired conversational partner may also be factors. For example, Herbert (unpublished research) observed that an agrammatic speaker had two very different conversations depending on her conversational partner. While interacting with her daughter she was required to produce very little in terms of lexical content but in conversation about holidays with a speech and language therapy student (whose approach was highly interrogative) the client’s contribution consisted primarily of nouns. The topic of conversation may also have been an influencing factor, as was the student’s role and lack of experience as a ‘therapist’. In unpublished work by Perkins, speech and language therapy students and their supervisors were asked to record themselves communicating with a client with the purpose of identifying what makes the difference between a student and an experienced therapist. Students exhibited two main types of communicative contribution. They were observed to be either too controlling or too accommodating. In contrast, the experienced supervisors struck a very fine balance between these two approaches. Differences in the perceived competence of augmentative aid users communicating with different communicative partners have also been anecdotally reported (Robillard, 1999). Exploration of these issues is difficult because of the range of familiarity and experience of communication partners as well as the additional factors that may also influence conversational interaction, for example the conversational partner’s gender, age, education and the context of the interaction. and attitudes. Recent work suggests that speech and language therapist-client talk is somewhere between institutional and peer interaction (Lindsay & Wilkinson, 1999). It is possible that speech and language therapy education and expertise permits clinicians to encourage somewhere near ‘normal’ conversations in a clinical context. While conversation within such a context is not representative of any or all other types of communicative interaction, it is representative of a clinical conversation, and such settings could provide an ideal context for sampling material in a consistent manner across time. The approach to sampling a communicative interaction can range from naturalistic to highly controlled and structured. A naturalistic sample might be a random sample of completely unstructured conversation between two peers and enables us to say something about how the people interact in the ‘real world’. A highly deal of caution is required in interpreting such data as it requires an appreciation of the sampling technique and some assumption of the degree to which the results are of relevance to another environment or setting. In light of these factors, it is vital that collected samples (and any contextualising details) are made available so that claims made from the results can be perceived by others.

Fundamental
The analysis approach chosen by a clinician should 1. provide information about what is important within the communicative interaction 2. aid diagnosis 3. inform effective therapy (which will in turn have a positive impact on the client’s communication) and 4. measure change over time. If an analysis of the use of discourse features during an interaction is to be used for diagnostic purposes then we need to know what the range of non-brain damaged communicative behaviour is on such a measure. This becomes essential when we are faced with an individual who may exhibit very subtle communicative problems, for example as a result of early Alzheimer’s disease or right hemisphere brain damage. Here the clinician must decide whether what they are listening to is within the range of normal communicative behaviour or not. The higher the language demand, the more blurred the distinction between a communicative pattern that is normal and one that is abnormal. (We all know someone whose normal communication could be described as impaired by a speech and language therapist!) Caution should be employed when analysing a sample as the extent to which we are informed of the participants’ communicative history may subconsciously influence the extent to which we observe ‘evidence’ of disordered communicative interaction. In Mackenzie et al. (1999) and Brady et al. (in press) an expectation that verbosity would be associated with right hemisphere brain damage was challenged when the most verbose individuals (as per word count) were in the non-brain-damaged groups. In such situations it is essential to have a general framework of normal conversational behaviour from which to objectively appraise subtle deficits. To make an unblinded differential diagnosis of such subtle deficits on the basis of a qualitative description of a sample alone is very difficult, if not foolhardy. Speech and language therapists are experts in discourse and conversational analysis and their knowledge - which may be informally acquired over time - should not be underestimated. However, it is vital that they examine not only their client’s contribution to a communicative interaction but also the communicative partner’s (in some cases their own) communicative behaviour. Transcribed data or video- or audio-recorded feedback can be used to alert the communicative partners to various features of the interaction. Some might question the
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

Transcribed data or videoor audio-recorded feedback can be used to alert the communicative partners to various features of the interaction
structured task might be the controlled elicitation of a procedural sample from a person with a communicative impairment with minimal contribution from the communicative partner. Such a sample will provide little information of relevance to the individual’s performance within a naturalistic conversation but allows some comparisons to be made over time and across individuals. The purpose of the two approaches to sampling differs, but with each we need to acknowledge how close the collected sample is to what is ‘real’. We no longer have the perception that what is observed in one type of discourse holds good for other genres. Individuals’ communicative interactions are likely to differ across contexts. For example, one client’s narrative sample may provide information of relevance to their conversational interactions but for another the narrative sample will have elicited data that is primarily sentential and bears little resemblance to their conversation. Other task-related factors should also be considered. For example, we know that a client’s age and educational background have an impact on their performance on a picture description task (Mackenzie et al., in press). Performance on such formal tasks may be related to an individual’s confidence in a test situation. On the other hand, some semi-structured elicitation cues can easily be introduced within a therapeutic conversation (for example ‘Tell me about your family’). These are rarely perceived by the client as a formal task and are thus less likely to provoke a confidence crisis. A great

Therapist-client talk
Interactions in a therapy setting are typically exchanges of information while interactions seen in less formal settings are characterised by an exchange of opinions

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THERAPY DIRECTION

value of identifying features that are only evident at a detailed transcription level, arguing that appropriateness is probably best perceived by the communicative partner within the context. There is now some indication that the expert therapist as an observer of a live or recorded interaction has the skills to note the use of such features without the need for in-depth transcription (Armstrong et al., in press). One of the difficulties with qualitative approaches is the vast range of discourse features that can be considered. As the body of literature builds, however, that information will in turn direct clinical focus towards features of note within an interaction. And as our knowledge increases through in-depth methods of descriptive analysis, this should feed into new clinically feasible approaches. While many therapists do not feel they have time to undertake the detailed transcription required for qualitative approaches to analysis and some lack confidence in the use of discourse terminology (turn-taking, repair, coherence), most seem keen to intervene at the practical level of discourse features within conversational interaction. There appear to be different perceptions as to how long qualitative analysis takes, but a means of making this rich source of information more accessible in clinical settings would be welcome. Communicative sequences are multi-layered and any proposed analysis tool for routine clinical use would need to provide more than superficial information. Clinicians require a tool that not only identifies the use of disordered features but also allows some description or explanation of how the participants are dealing with the features to inform an appropriate intervention. A first step may be to develop tools that work at a superficial level. Categorical counts sensitive to change at a conversational level or frameworks to allow the analysis of communicative interaction in an objective and efficient way are two possible starting points. Some advances towards this goal have already been made (Lock et al., 2001).

from family members are also likely to be relevant. In the past we have probably underestimated how hard it is to change communication behaviour at conversational level, perceiving that successful therapeutic interventions targeted at word or sentence level would automatically - or with a little support - be generalised to conversational level. But some features of conversational interaction are probably not under our conscious control - and individuals without a communicative impairment have difficulty changing their communication style! Yet we continue to expect that people (in some cases with associated brain damage) will change their communication behaviour with very little effort. Despite huge therapeutic effort amongst some (for example, individuals with traumatic brain injury), conversations can still go wrong in context and this may indicate that deficits at other cognitive levels also require attention.

If the therapeutic focus is to shift towards conversational level interventions then a change in clients’ perception of ‘therapy’ and what it has to offer is required.
Yet change at the conversational level of interaction is vital for therapy to make a difference in that individual’s life and the lives of his family and friends. If the therapeutic focus is to shift towards conversational level interventions then a change in clients’ perception of ‘therapy’ and what it has to offer is required. Speech and language therapy students at the University of East Anglia (in collaboration with Connect) have become conversational partners for people with aphasia, yet some of the people with aphasia have found the concept of someone coming ‘just’ to have a conversation with them challenging.

Evidence
The link between quantitative approaches to assessment and impairment-based therapy has been well documented. Formal quantitative approaches provide concrete evidence that therapy is efficacious and this evidence is accessible to (and increasingly sought by) clinicians, clients, family members, managers and policy makers. The link between qualitative approaches to analysis and therapeutic intervention however has not been adequately demonstrated and should be urgently addressed. For example, a substantial amount of work has been carried out training conversational partners and, while we can say their conversation is better, we should be able to prove it. Quantification provides evidence of effectiveness in a way a single case study will never do. However, we also know that the effectiveness of therapy is related to the impact of the intervention on the quality of the individual’s daily communicative life. Quantifying change on selected outcomes using valid and reliable assessment tools of communicative improvement may be complemented using other qualitative approaches. For example, psychosocial indicators of whether the client with traumatic head injury is able to develop friendships, avoid confrontations or is confident enough to participate socially (for example, go to the pub) are all valid indicators of change. Reports of improvement

Ownership
Clinicians have a responsibility to choose the best approach to intervention for a particular client and their family - and that may not always be at conversational level. Developments in therapeutic interventions have progressively evolved towards focusing on both the client and the conversational partner within an interactional setting. However, this (by design) takes the focus away from the person with aphasia. We need to acknowledge that people have different learning styles and some people with aphasia actually enjoy the more formal, quantitative approaches to assessment as well as impairment-based therapy. They find they can explore the full extent of their language disorder and develop an understanding of what they can and cannot do. They can regain a sense of control over their impaired communication from insights gained through testing and a sense of achievement from successfully completed tasks. Although aphasia affects all the communicative participants within an interaction, the person with the impairment retains ownership. Therapeutic intervention increasingly includes working with communication partners (usually family members and friends). This development is no doubt a reflection of the difficulty many client groups have in independently

changing their communication patterns. It is well recognised that small therapist-enacted changes to the communicative context, such as getting a partner to make greater use of pauses, can suddenly make a person with communication impairment seem much more competent by allowing them to contribute to the interaction. In the past there was a perception that a conversational partner ‘pushing for’ or encouraging a better response was a positive thing. Education on the nature of the communication deficit and suggestions for successful management strategies for certain communication habits can take some of the pressure off communication partners without them feeling the need to produce a painful emulation of therapy. Some partners (and clients) can have significant insight into how they are coping with the communication impairment and the strategies that they are using to overcome them, yet we should be cautious of putting the onus of successful communication solely on them. It would be useful to be aware of the limits of possible change not only for the communicatively-impaired individual but also the extent to which a communication partner, for example the elderly spouse of an individual post-stroke, can be trained to change their conversational style and improve their communicative support. Different approaches are likely to be required for different client groups. For example, there may be some scope in the consideration of hard-line behaviour modification, pharmacological co-interventions and social decision making models when working with individuals with traumatic brain injury. Such approaches are however unlikely to be appropriate when working with individuals with aphasia. With the possibility of subtle interactional impairments merely being a symptom of (or an adaptation to) a non-linguistic underlying cause, speech and language therapists are increasingly working collaboratively with other professionals. While an interest in conversation level impairment and intervention is appropriate, it should not be to the exclusion of other approaches. Interventions based on cognitive neuropsychology have proved to be effective (as measured by increased test scores) but the therapeutic community appears to have become disinterested. Efforts should be made to understand whether interventions demonstrated to be effective are also effective at conversational levels. For example, we should consider to what extent improvements in word finding can be understood within the context of everyday communicative interactions. It is crucial to consider what happens outside the clinic and about how the individual lives with the communication impairment. We talk about ‘living with dysarthria’ or ‘living with aphasia’ and look at communicative impairment in an adaptive way. However, the infrastructure and technology that is required to help people to live with their communication impairment is as yet unavailable and so to some extent therapy - and more disappointingly the individual - is still constrained within a deficit model.

Stories of success
Clinicians have many stories of both success and failure. Analysis is mainly deficit and impairment focused, with little consideration given to how therapy works and, when it does work, why. We should pay more attention to our success stories by considering the circumstances in which the intervention proved to be beneficial. While

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

HERE’S ONE I MADE EARLIER...

qualitative approaches to analysis provide many ideas for conversational level interventions, we also need to work at translating those into successful therapy. Where success has been achieved then we must communicate this to others to enable the ongoing development of our interventions. If there is evidence of effectiveness then clinicians can justify spending time on analysis that will inform effective interventions. Together, quantitative and qualitative approaches to analysis add to the potential richness of data collected. We look forward to these two approaches evolving towards a single analysis methodology that represents combined elements, thus allowing a quantification of the use of discourse features. Address for correspondence: Marian Brady, Nursing, Midwifery and Allied Health Professions Research Unit, Buchanan House, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA.

Heres one I made earlier...
ALISON ROBERTS WITH MORE LOW-COST, FLEXIBLE THERAPY SUGGESTIONS SUITABLE FOR A VARIETY OF CLIENT GROUPS.

I. LUCKY DIP REPORTING GAME
“This game helps to develop lateral thinking and narrative skills in fairly able clients. The idea is for the clients to become ‘Reporters’, who provide a main idea, and then give a few details to go with a newspaper headline that they have picked out of a container. Playing this game also provides an opportunity for you to suggest that keeping up-todate with and being able to talk about real news can be a good conversation skill.” MATERIALS • Plenty of headlines cut out of newspapers - vague themes are best, rather than headlines that restrict the reporter to one particular story • Some sort of container such as a basket, hat, or bag • Small envelopes BRAWN Place each headline in an envelope. This is preferable to just putting them straight into the container, because otherwise you risk them getting ripped. Also, in this way, the headline can be kept private to the ‘reporter’, avoiding others chipping in. IN PRACTICE • Clients are asked to pick out an envelope, look at the headline, and then provide a short report to follow it. Request that they keep the headline to themselves until they have a rough idea of their report. Suggest that they then read out their headline, and follow it with a main theme, then two to three details. • It’s good if you go first to demonstrate. Let’s say the headline reads: ‘Phew! What a scorcher!’ You could give a main theme: “Temperatures reached 35 degrees centigrade in Gloucestershire today”, then supply three details: “Farmer John Smith had to keep his cattle indoors today to stop them getting heatstroke. He put the hoses on to spray them. He blamed global warming for this problem”. • Reward clients for reports of the right length. Those who tend to ‘ramble’ will benefit from having to be short and to-the-point, whilst your clients who tend to offer one word as a response must elaborate a bit.

II. ‘ALL ABOUT ME’ BOXES
“This is a self-awareness activity. It is best done over several sessions, taking time to complete the boxes to a good finish and talk them through. You can carry out this activity with just one client, or in a group. A word of warning: this activity should be carried out in a light-hearted atmosphere - you are not trying to be a psychotherapist. My advice is to make one about yourself before the session, which you are prepared to open to reveal the contents, but state clearly that they will not have to reveal the contents of their boxes to others if they do not wish to.” MATERIALS • Small (about 6cms x 6cms x 2 cms) plaincoloured cardboard boxes available from craft shops. The best sorts have a frame within the lid. If you really cannot run to that expense, then the small individual cereal boxes sold in packs are a good substitute, but you will need to paint them white before decorating, and make a neat opening at one end. • A photo of your client • Felt-tip pens • Small pieces of paper or card • Sticky tape IN PRACTICE (I) The outside of the box is decorated with the felt tips, and with words to show the world what this person is good at, or likes to do, and should include their name. This part is open for others to inspect. Inside the box your client will place the small pieces of paper or card with words to describe their secrets, fears, disappointments, dreams, etc. It is important for the clients to be sure that the boxes are kept in a secure place, and that you will not look inside without their permission. When they have completely finished making the boxes they may like to seal them with sticky tape. If your client is happy to do so, they will stick their photo on the lid of the box, within the frame. IN PRACTICE (II) This is good for the group setting. Begin the writing of the cards for inside the box with some less ‘sensitive’ topics, for example preferences (favoured holiday resorts; music; types of food), or aspects of the clients’ biographies (birthday;place where their childhood was spent; schooling). Pool all of the cards, and take turns to pick one out and guess who wrote it, before placing it in its owner’s box.

Acknowledgement
We would like to thank Dr. Ellen Townend and Elizabeth Stirrat for transcription of the discussion sessions.

References
Armstrong, L., Brady, M., Mackenzie, C. & Norrie, J. (in press) ‘Transcription-less analysis of aphasic discourse: a clinician’s dream or a possibility?’, Aphasiology. Brady, M., Armstrong L. & Mackenzie, C. (in press) ‘Change over time in linguistic abilities in people with right hemisphere brain damage?’ Journal of Neurolinguistics. Lindsay, J. & Wilkinson, R. (1999) ‘Repair sequences in aphasic talk: a comparison of aphasic-speech and language therapist and aphasic-spouse conversations’, Aphasiology, 13, pp. 305-326. Lock, S., Wilkinson, R. & Bryan, K. (2001) Supporting Partners of People with Aphasia with Relationships and Conversation (SPPARC). Bicester: Speechmark Publishing. Mackenzie, C., Begg, T., Lees, K.R. & Brady, M. (1999) ‘The communication effects of right brain damage on the very old and the not so old’, Journal of Neurolinguistics, 12, pp. 79-93. Mackenzie, C., Brady, M., Norrie, J. & Poedjianto, N. (in press) ‘Picture description in neurologically normal adults: concepts and topic coherence’, Aphasiology. Perkins, M.R. (2005) ‘Pragmatic ability and disability as emergent phenomena’, Clinical Linguistics and Phonetics 19, pp. 367-377. Perkins, M.R., Catizone, R., Peers, I., & Wilks, Y. (1999) ‘Clinical computational corpus linguistics: a case study’, in B. Maassen & P. Groenen (eds.) Pathologies of Speech and Language: Advances in Clinical Phonetics and Linguistics (pp. 269-274). London: Whurr. Robillard, A. (1999) Meaning of a Disability – the Lived Experience of Paralysis. Philadelphia: Temple University Press. SLTP REFLECTIONS • DO I HAVE REALISTIC EXPECTATIONS OF HOW MUCH A COMMUNICATIVE PARTNER CAN ADAPT THEIR COMMUNICATION? • DO I HAVE A FLEXIBLE APPROACH TO THE DIRECTION OF THERAPY THAT TAKES INTO ACCOUNT THE LEARNING STYLE AND WISHES OF THE INDIVIDUAL CLIENT? • DO I PARTICIPATE IN EVENTS THAT GIVE CLINICIANS, RESEARCHERS AND ACADEMICS TIME TO PAUSE AND REFLECT TOGETHER?

Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

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